Gouëffic Yann, Chaillou Philippe, Pillet J Christophe, Duveau Daniel, Patra Philippe
Department of Vascular Surgery, Guillaume et René Laënnec Hospital, Boulevard J Monod St Herblain, 44093 Nantes cédex 1, France.
J Vasc Surg. 2002 Dec;36(6):1186-93. doi: 10.1067/mva.2002.128933.
Atherosclerotic lesions of the aortic arch are potential sources of arterial embolism. Here we investigate whether surgery, with the necessary circulatory supports, can be proposed as a good option for treatment of this problem. Study of these lesions on a national scale in France has made possible the assessment for future indications of techniques and results of the surgical management of aortic arch lesions, which retrospectively proved to be embolic.
Thirty-eight patients, (19 men and 19 women) underwent surgery between 1976 and 1996 in 17 French cardiovascular surgical centers. The average age at the time of surgery was 49 +/- 12 years (range, 31 to 82 years). Atherosclerotic lesions were detected with transesophagial echocardiography (n = 19), angiography of the aortic arch (n = 16), computed tomography (n = 9), and magnetic resonance imaging (n = 10). Surgery consisted of thrombectomy and endarterectomy (n = 22), aortic resection and graft replacement (n = 10), and patch aortoplasty (n = 5; one thrombus disappeared spontaneously before surgery was performed).
The average postoperative period was 30 months (range, 3 to 82 months). Contact was lost with four patients after a follow-up period of 12 months. On pathologic specimens obtained at surgery, an atherosclerotic plaque was found in 73% of the cases (n = 28). In 15% of the cases, the aorta appeared normal (n = 6) and four other types of lesion were identified: angiosarcoma (n = 1), ectasia at the insertion of the remains of the ductus arteriosus (n = 1), rupture of tunica intima (n = 1), and a fibroblastic plaque (n = 1). A thrombus was identified in 26 cases, attached to the arterial wall in 18 cases. When transesophagial echocardiographic results showed mobile lesions (n = 22), histopathologic examination of specimens allowed the detection of a thrombus in 18 cases and an atherosclerotic plaque with a mobile projection in four cases. The postoperative mortality rate was 2.6%. The morbidity rate (28.9%; n = 11) was related to neurologic complications (n = 6), vascular complications (n = 4), and infection (n = 1). Four cases (12%) were reoperated.
Nonaneurysmal aortic arch lesions are a frequent and still underestimated source of stroke and peripheral embolization. Surgery with circulatory support can be recommended in good operative candidates with recurrent critical events despite medical management and with high embolic potential (young patients with no calcified plaques).
主动脉弓的动脉粥样硬化病变是动脉栓塞的潜在来源。在此，我们研究在具备必要循环支持的情况下，手术是否可作为治疗该问题的良好选择。在法国全国范围内对这些病变进行研究，使得评估主动脉弓病变手术治疗的技术未来适应证及结果成为可能，而这些病变经回顾性证实为栓塞性病变。
1976年至1996年期间，17家法国心血管外科中心的38例患者（19名男性和19名女性）接受了手术。手术时的平均年龄为49±12岁（范围31至82岁）。通过经食管超声心动图（n = 19）、主动脉弓血管造影（n = 16）、计算机断层扫描（n = 9）和磁共振成像（n = 10）检测到动脉粥样硬化病变。手术包括血栓切除术和动脉内膜切除术（n = 22）、主动脉切除术和移植物置换术（n = 10）以及补片主动脉成形术（n = 5；1例血栓在手术前自行消失）。
术后平均时间为30个月（范围3至82个月）。随访12个月后，4例患者失访。在手术获取的病理标本中，73%的病例（n = 28）发现有动脉粥样硬化斑块。15%的病例（n = 6）主动脉外观正常，还识别出其他四种类型的病变：血管肉瘤（n = 1）、动脉导管遗迹插入处扩张（n = 1）、内膜破裂（n = 1）和成纤维细胞斑块（n = 1）。26例病例中发现有血栓，18例血栓附着于动脉壁。当经食管超声心动图结果显示有活动病变时（n = 22），标本的组织病理学检查在18例中检测到血栓，4例中检测到有活动突出的动脉粥样硬化斑块。术后死亡率为2.6%。发病率为28.9%（n = 11），与神经并发症（n = 6）、血管并发症（n = 4）和感染（n = 1）有关。4例患者（12%）接受了再次手术。
非动脉瘤性主动脉弓病变是中风和外周栓塞的常见且仍被低估的来源。对于尽管接受了药物治疗但仍有复发性严重事件且具有高栓塞风险（无钙化斑块的年轻患者）的合适手术候选者，可推荐进行有循环支持的手术。
